Declining and rebounding unhealthy alcohol consumption during the first year of HIV care in rural Uganda, using phosphatidylethanol to augment self-report

Abstract

Aims We examined whether unhealthy alcohol consumption, which negatively impacts HIV outcomes, changes after HIV care entry overall and by several factors. We also compared using phosphatidylethanol (PEth, an alcohol biomarker) to augment self-report to using self-report alone. Design Prospective one-year observational cohort study with quarterly visits. Setting Large rural HIV clinic in Mbarara, Uganda. Participants 208 adults (89 women and 119 men) entering HIV care, reporting any prior year alcohol consumption. Measurements Unhealthy drinking was PEth+ (≥ 50 ng/ml) or Alcohol Use Disorders Test – Consumption+ (AUDIT-C+, over 3 months, women ≥ 3; men ≥ 4). We calculated adjusted odds ratios (AOR) for unhealthy drinking per month since baseline, and interactions of month since baseline with perceived health, number of HIV symptoms, anti-retroviral therapy (ART), gender, and self-reported prior unhealthy alcohol use. Findings The majority of participants (64%) were unhealthy drinkers (PEth+ or AUDIT-C+) at baseline. There was no significant trend in unhealthy drinking overall (per-month AOR: 1.01; 95% CI: 0.94–1.07), while the per-month AORs were 0.91 (95% CI: 0.83–0.99) and 1.11 (95% CI: 1.01–1.22) when participants were not yet on ART and on ART, respectively (interaction p-value <0.01). In contrast, 44% were AUDIT-C+; the per-month AORs for being AUDIT-C+ were 0.89 (95% CI: 0.85–0.95) overall, and 0.84 (95% CI: 0.78–0.91) and 0.97 (95% CI: 0.89–1.05) when participants were not on and on ART, respectively. Conclusions Unhealthy alcohol use among Ugandan adults entering HIV care declines prior to the start of anti-retroviral therapy but rebounds with time. Augmenting self-reported alcohol use with biomarkers increases the ability of current alcohol use measurements to detect unhealthy alcohol use.

Randomized Study of Assessment Effects on Alcohol Use by Persons With HIV in Rural Uganda

“…In addition, we were not able to independently assess behavior change resulting from study participation (Hawthorne Effect) because all of our participants were enrolled in the study. However, we have previously reported that there were no reductions in unhealthy alcohol use measured by a combination of PEth and self-report across the first year of HIV care in this cohort; therefore, we suspect little overall study effect (Hahn et al, 2016). All assessments in our study were intervieweradministered; as such, our results may not be generalizable to other types of assessment, including self-assessments.…”

“…The study was called the Biomarker Research on Ethanol Among Those with HIV (BREATH) Study (Asiimwe et al, 2015;Hahn et al, 2016). Study subjects were patients of the Immune Suppression Syndrome (ISS) Clinic in Mbarara, Uganda, who were new to HIV care.…”

“…After enrollment, collection of tracking information, and randomization, the quarterly assessed arm received an intervieweradministered structured interview along with breath alcohol concentration testing and phlebotomy at baseline and quarterly thereafter (Asiimwe et al, 2015;Hahn et al, 2016). Additional assessments in the quarterly assessed arm included T-helper cell (CD4) count and viral load tests at baseline as markers of HIV disease progression.…”

“…The sample size for this study was determined to obtain precise estimates of drinking across 1 year in HIV care, the main aim of the BREATH Study (Hahn et al, 2016). For that analysis, we calculated that we would need to enroll 212 persons into the quarterly assessed arm; expecting 15% loss to follow-up, we would have 180 persons for analysis to estimate unhealthy drinking with a 95% confidence interval (CI) that was at most 15% wide.…”

“…Previous studies of assessment reactivity have relied on self-reported behavior; however, there is evidence of a high degree of socially desirable reporting on alcohol use among persons in HIV care in Uganda (Bajunirwe et al, 2014;Hahn et al, 2012Hahn et al, , 2016. Thus, objective measures of alcohol consumption, such as the alcohol biomarker phosphatidylethanol (PEth), are needed to examine this issue.…”